This blog was contributed by Nancy Lawton-Shirley, OTR/L who will be teaching the two-day Session H. CranioSacral Applications in Pediatrics. Nancy owns Points of Stillness, which offers occupational therapy at Healing Waters Health Center in Hudson, WI.

1. Be sure your child has physical activity after school. Time outside is ideal. Free time to just play can really recharge a child's brain from a day of structure. Self-directed play is a great way to work the creativity parts of the brain!
2. Have snacks available during study time. Things to chew, suck and crunch actually help the brain to pay attention, focus and learn.
3. Do memory tasks while a child does rhythmic movement, i.e. sitting on a ball and bouncing or jumping up and down while they spell a word or learn math. Rhythm lays down memory faster!
4. Try watching the MeMoves DVD! Have the family do one set of the exercises on the DVD. It very quickly calms everyone down, and gets the brain ready to learn. This is good for preschool- through high school-aged children!
5. Some children need absolute quiet to concentrate. Other children really benefit from playing music with a consistent beat. Ideas:Baroque for Modulation, Sacred Earth Drums, Calming Rhythms.

And remember your child has been working hard all day!

This contribution is from 3rd Symposium speaker Shelley Mannell, PT, from her recent blog at HeartSpace Physical Therapy. 



When I first became a pediatric PT we talked about primitive postural reflexes as part of the development of postural control.  We certainly didn't have all the answers and there were many different perspectives, so these were lively conversations with lots of good clinical problem solving. But references to primitive reflexes had mostly disappeared from the discourse on postural control until fairly recently.  

We used to think of development as a hierarchical process. But as our understanding of how the brain works has improved, we now understand it as a complex, dynamic, multi-systems process. So rather than primitive reflexes, I prefer to use the term developmental reflexes - stereotypical movement patterns triggered in response to a sensory stimulus representing our first developmental experiences with registering and responding to our position in space. Babies experience extension and flexion of their body (Moro), their relationship to the support surface (TLR), differentiation of left and right sides of their body (ATNR) as well as the dissociation of their upper body from their lower body (STNR) – all with reference to their head position.  As such, they lay down the early sensory and motor neurological wiring which supports the development of mature postural control.  And even when mature postural control is present, if the system is stressed or damaged, these patterns reappear to help out with stability.  One has only to watch me try to ski a beginner's hill to view a classic ATNR! 

 

Regardless of their usefulness, many clinicians and the literature 1-3 tend to agree that their continued presence in everyday activities is an indicator of postural control difficulty. We also understand that they can interfere with functional skill development.  This leads us to the next question - how might we address them in treatment?

My preference is to work from the inside out in building a clinically relevant understanding of the sensorimotor development of postural control. Early postural control is characterized by developmental reflexes, while mature postural control is characterized by both anticipatory and reactive components. Recent research has yielded some exciting information regarding the organization of central stability, alignment, pressures, recruitment of inner core muscles and activation of outer core muscle groups in different client populations.  We can leverage this new information in treatment of children with sensory and motor challenges, as we build and blend these developmental reflexes into more mature postural control, which ultimately serves to support complex motor, perceptual and emotional regulation skills. 

These new conversations have raised more questions and I'm excited once again by discussions that are filled with new research, clinical observations and problem solving.  Please join me for a 2-day adventure as we explore the theory, practical applications and treatment strategies regarding developmental reflexes in Function From the Inside Out: Sensory and Motor Processing for Postural Control as part of the RAIR Symposium in Bloomington MN Feb 26-27, 2016.   


1.     Sohn M, Ahn Y, Lee S. Assessment of primitive reflexes in high-risk newborns.  J Clin Med Res. 2011; 3(6): 285-90.

2.     Tribucci AT, Penedo-Leme S, Funayama CAR.  Postural adjustment as a sign of attention in 7-month-old infants.  Brain Dev. 2009; 31: 300-6.

3.    Konicoarova J, Bob P.  Asymmetric tonic neck reflex and symptoms of attention deficit and hyperactivity disorder in children.  Int J Neurosci. 2013;  DOI: 10.3109/00207454.2013.801471.

 

photo credit leader.pubs.asha.org

3rd Symposium speaker Renée Okoye, OTR, of Dove Ministries for Children, has written an extensive article for their summer newsletter, describing the function and treatment of the vestibular system. In a clear and readable form, with attractive illustrations, the article is packed with information helpful to parents and other professionals. Go here to view the entire article.

Renée will be teaching Session B: Documenting Sensory Performance in an Academic Environment 

Check out this interview with upcoming speaker Diane Bahr. Reposted with permission from Ages and Stages.



How do you keep your child's mouth in shape from birth? The Scoop on Pacifier-Use, Thumb-Sucking, and Mouth Toys.

February 2015

Interview with Diane Bahr (DB) by Dr. Teresa Signorelli (TS) of Kids A to Z with Dr. T (February, 2015)

The following is the summary of a radio interview with Diane Bahr by Dr. Teresa Signorelli of Kids A to Z with Dr. T. You may listen to the actual interview by clicking on the “radio interview” link in the previous sentence. This interview is a continuation of discussions begun in October and November of 2014 about feeding and mouth development.

In this interview, we discuss a little more information from the book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. This book was written as a resource for both parents and professionals (e.g., speech-language pathologists, occupational therapists, orofacial myofunctional therapists, lactation consultants, pediatricians, dentists, nurses, early interventionists, and others). It contains many detailed checklists and practical techniques that parents and others can use to keep kids “on track” in feeding, speech, and mouth development (beginning at birth).

TS: Would you tell us who you are and what you do?

DB: I’m a speech-language pathologist, specifically trained in oral sensory-motor and feeding therapy, with over 30 years of experience. I’ve authored two books Oral Motor Assessment and Treatment: Ages and Stages and Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. I’ve taught undergraduate, graduate, continuing education, and parent education courses. I’m also the co-owner of Ages and Stages®, LLC (Resources for Feeding, Speech, and Mouth Function) where our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents and professionals keep children “on track” developmentally.

TS: What is the most common concern you find parents have about mouth development?

DB: With so many older children wearing braces, having palatal expanders, and being diagnosed with sleep apnea, parents want to know what they can do from an early age to help their children develop the best possible mouth and airway structures.

TS: What are parents often surprised to learn regarding mouth development?

DB: A significant amount of mouth and airway development occurs in the first year of life when the structures are growing rapidly. As we discussed in previous interviews, mouth and airway development are interconnected because they share common structures such as the hard palate (roof of the mouth). Parents can help make a difference in how their children’s mouths and airways develop by the feeding processes they use and the mouth play they encourage.

TS: Let’s talk about the process of mouth development? Can you begin by telling us something about the hand-mouth connection?

DB: In Chapter 4 of my book Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development, I talk about the hand-mouth connection. Hands and mouths work and develop together from birth.

This begins with the hand and mouth reflexes with which babies are born. These are the palmomental, Babkin, and grasp responses. When you touch a baby’s palm, the mentalis muscle is activated, which helps the baby’s lower lip evert for the latch. When you press the base of the baby’s palm, “the baby’s mouth opens, eyes close, and head moves forward” which helps with feeding. When you place your finger into a baby’s palm, the baby grasps the finger. This grasp tightens when the baby sucks. A baby’s hand-mouth connection can often be seen on ultrasound while the baby is still in utero (e.g., thumb, hand, and foot suckling).

TS: You talk in your book about the development of mouthing. Can you tell us something about that?

DB: Babies go through a developmental mouthing process during the first two years of life. I’m going to talk mainly about the first year because this is information many parents don’t get to hear.

There is a period of generalized mouthing from birth until around 5-months of age. During this period, babies suck on their fists, fingers, and thumbs mostly near the front of their mouths. Around 3-months of age, babies gain increased control over the mouthing process. This is a time when parents can help a baby hold an appropriate mouth toy to the mouth. The baby will suck and bite on the toy.

By 5 to 6-months of age babies develop even more oral control and begin the process of discriminative mouthing. At this age, a baby needs appropriate mouth toys that the baby can explore throughout the mouth, not just in the front of the mouth. This helps a baby develop sensory discrimination within the mouth that he or she will ultimately use for food manipulation and speech. Many parents don’t know about the discriminative mouthing process, and many mouth toy manufacturers do not provide appropriate mouth toys for this process.

TS: You mentioned “discriminative mouthing” and that many toy manufacturers do not provide appropriate mouthing toys. Would you tell us what you mean by “discriminative mouthing” and what appropriate mouth toys might look like?

DB: Discriminative mouthing is when a baby uses the mouth like a “third hand” to explore hands, fingers, and mouth toys. The toys need to be large enough so the baby won’t swallow or choke on them but small enough so the baby can move the toy safely throughout the mouth. These toys are often triangular in shape or have protuberances that the baby can move all around the mouth.

For young babies, I like ARK’s Baby Grabber, Debra Beckman’s Tri-Chews, and the Chewy-Q from Chewy Tubes. These items are made in the USA from FDA approved materials. I provide information in my book on where to purchase them. However, parents can look for toys with the qualities we discussed. There are small mouth toys shaped like keys and Lively Links that can also be used for discriminative mouthing.

TS: How are mouthing and teething related?

DB: Mouthing is an important part of the teething process. Mouthing, biting, and chewing on safe and appropriate mouth toys and foods seem to be crucial to the emergence of teeth. The primary teeth emerge mostly during the first 2-years of life. We see many children today who go through prolonged periods of sucking on pacifiers and thumbs without appropriate mouthing, biting, and chewing experiences. We also see many child whose teeth do not seem to be emerging on time and in the proper sequence. In my experience, children need to bite and chew on toys and appropriate foods in order to get teeth.

TS: There a number of common mouth development problems. Let’s talk about what they are and what parents can do about them. Let’s start with the problem of having a high-narrow palate or roof of the mouth.

DB: As we discussed in our previous interviews, high-narrow palates (roofs of the mouth) usually cause the child’s nasal and sinus areas to become smaller than usual. This makes the child’s upper airway smaller and more difficult to clear which may contribute to unhealthy mouth breathing, allergies, sinus problems, and sleep apnea. High narrow palates usually result from low resting tongue postures (where the tongue sits in the bottom of the mouth instead of resting within the hard palate area). Therefore, it is important for a baby to have time throughout the day and night for the tongue to rest properly within the mouth with the mouth closed at rest (without a pacifier or thumb).

It is a closed mouth at rest with the tongue resting in the palate area that helps to maintain the hard palate’s shape. Breastfeeding is also a nice natural way to help maintain the hard palate’s shape because the breast is drawn deeply into the baby’s mouth to fill the palate area while the baby is feeding. Unfortunately, bottle feeding does not provide the same benefit. Additionally, I have a jaw activity in my book that parents can do with their babies from birth that may help maintain the palate’s shape and assist with the growth of the lower jaw.

TS: Yes, so I understand there can be problems with mouth development that result in overbites, underbites, or other issues. What can you tell us about that?

DB: In my experience, babies who suck excessively without other mouth experiences can have over growth of the upper jaw (leading to an overbite or overjet) and limited growth of the lower jaw (leading to a weak chin and limited airway development). The lower jaw seems to require the biting and chewing experiences we discussed previously to grow forward, which then helps the airway area behind the jaw to develop properly. And, these issues can become very apparent by one-year of age, if not before.

Overbites (top front teeth too far in front of bottom teeth), overjets (top jaw too far in front of bottom jaw), and open bites (opening between the top and bottom teeth) usually result from some form a of a tongue thrust swallow. Tongue thrust swallow may also be referred to as reverse swallow or exaggerated tongue protrusion. This is an unsophisticated form of the swallow where the tongue moves forward in the mouth (often against the front teeth) to begin the swallow, instead of the tongue tip rising up to the ridge behind the top front teeth to initiate or start the swallow. 

Underbites (bottom teeth and jaw protrude in front of top teeth and jaw), cross-bites (where the top and bottom teeth cross each other and do not fit together properly), and closed-bites (where teeth meet edge to edge) usually result from jaw development problems in my experience. Typically, when the top and bottom jaws come together, the top teeth are supposed to be slightly in front of the bottom teeth with the molars meeting properly in the back of the mouth, like a lid fitting onto a container (as described by my colleague Marge Foran who is an orofacial myofunctional therapist).

In Chapter 8 of my book, I discuss appropriate mouth development from birth to adolescence. I also talk about the specific mouth development problems we have just discussed and who to see if a child has these issues.

TS: So we’ve discussed some of the problems with mouth development. What can parents do to prevent or resolve these issues? Who are the right professionals with whom to consult?

DB: Parents can help prevent problems by tracking their children’s mouth development from birth and using appropriate feeding and mouth development activities with their children. As you know from our previous interviews, this is one reason I wrote my parent-professional bookNobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development. I want parents to have the information we as therapists have about feeding, speech, and mouth development.

However, if parents have not had the opportunity to encourage good mouth development from birth, I suggest they take a look at their child’s mouth development and get appropriate help if needed. As I mentioned before, I have mouth development information (from birth to adolescence) in Chapter 8 of my book.

Now, I don’t want parents to look at the information in Chapter 8 and feel guilty if their children have any of the mouth development problems we’ve discussed. You can’t prevent something you don’t know about as a parent. So, my book is an information book to help parents and their children move forward in the process of mouth development.

There are many specialists available to help parents and children with this process when problems arise. Oral sensory-motor specialists and orofacial myofunctional therapists usually work in conjunction with orthodontists, dentists, oral surgeons, and otolaryngologists (i.e., ear, nose, and throat doctors) to help resolve many of the mouth development issues we have discussed. As an oral sensory-motor specialist, I specialize in jaw and feeding work. If the jaw isn’t working properly, the lips and tongue cannot work properly. Orofacial myofunctional therapists specialize in correcting the resting tongue position and the swallow. There are also dentists who specialize in orthotropic work and functional jaw orthopedics. You can find information about these specialists in Chapter 9 of my book and on my website.

TS: Let’s talk about pacifiers and thumb-sucking. Pacifiers are popular with parents to sooth children. Children may also suck their thumbs for a similar purpose. What do you see as appropriate pacifier use versus overuse?

DB: In Chapter 4 of my book, I provide parents with guidelines for appropriate pacifier use and thumb-sucking. As you said, sucking can be very soothing for a young baby.  

With regard to pacifier use, there was a study of almost 500 children in the year 2000 that demonstrated a connection between long-term pacifier use and middle ear problems. So, in my book I recommend guidelines for pacifier use based on this study. In my opinion, pacifier use is most appropriate for calming babies from birth to 5 or 6-months of age. A child should also be given the opportunity to self-calm with his or her own hands during this time. A calm child doesn’t need a pacifier, thumb-sucking, or finger/digit sucking. When a child overuses a pacifier, it limits the child’s opportunities for communication (e.g., the development of facial expression, cooing, babbling, etc.) in addition to other appropriate mouth experiences.

By 5 to 6-months of age, the child should be using appropriate mouth toys for teething and discriminative mouthing. This activity can also be soothing and calming, and it can increase attention, focus, and concentration. Adults often chew gum for these purposes. They hopefully don’t suck on pacifiers, thumbs, or digits to calm and organize themselves. I usually recommend that parents provide appropriate mouth toys for their children throughout the day and while they look at books together.

The 5 to 6-month period is also a time when many new feeding experiences are introduced as we discussed in our first interview. The baby learns many new mouth movements with these feeding experiences.

Dr. Harvey Karp is the pediatrician who wrote the book The Happiest Baby on the Block. In his book, he recommends that parents discontinue the pacifier at 4 to 5-months of age. The study of almost 500 children (mentioned previously) recommends parents wean their children from the pacifier between 6 and 10 months of age. It was beyond 10-months of age that a correlation was found between pacifier use and middle ear problems in the study. By the way, I also encourage parents to follow similar guidelines to wean children from thumb and finger/digit sucking. However, thumbs and fingers are attached to the child, so weaning may be a little trickier than weaning from a pacifier.

TS: Now, I understand you have an 8-step process parents can use to help wean children from using a pacifier, sucking their thumbs, or engaging in other sucking behaviors. Would you walk us through that? As you do this, would to tell us tips you have for parents to wean their children from pacifiers and how parents can decrease and eliminate thumb-sucking?

DB: As you mentioned, I have an 8-step process for weaning children from the pacifier, thumb, or other sucking habits in my book. The key is to find appropriate mouth toys to replace the pacifier, thumb, or digits when the timing is right. I usually start early by having parents introduce mouth toys hand-over-hand beginning around 3-months of age. Weaning can be complete in some children by 5 or 6-months of age as suggested by Dr. Karp or even earlier. It can be a quite natural and easy process when the child is ready.

The mouth toys used in the weaning process need to be something enjoyable and appropriate for the baby or child. In Chapter 5 of my book, I have a chart with recommended mouth toys by age. As previously mentioned, I like ARK’s Baby Grabber, Debra Beckman’s Tri-Chews, and theChewy-Q from Chewy Tubes for young babies. Both ARK and Chewy Tubes have a range of safe and appropriate mouth toys. Their items are made in the USA from FDA approved materials. I provide information about these and other companies in my book.

Another key to the weaning process is to provide positive attention (e.g., a smile and/or kind words like “Look at how much fun you are having with your toy.”) when the child is using an alternative item for mouthing in place of a thumb or pacifier. At first, you praise the child frequently for using new mouth toys. Over time, you praise the child intermittently or occasionally as he or she naturally mouths the appropriate toys you’ve introduced. The child will no longer need constant praise for this process.

When helping children break habits such as thumb or finger/digit sucking, I suggest you ignore the habit but not the child. You can just act as if the child is not participating in the habit. I don’t recommend bringing attention to the habit by saying “Take that out of your mouth.” This can actually reinforce the habit in some children. If you have an older child who has a detrimental oral habit, you may need to work with the child on a specific plan to eliminate the habit.

TS: What are the potential ramifications of pacifier overuse and thumb-sucking?

DB: We call thumb and pacifier sucking detrimental oral habits when they continue beyond infancy because they tend to lead to low tongue resting postures and some form of a tongue thrust swallow, which (as you know) can result in a number of mouth development problems.

TS: You have a wonderful website and networking program for families and related professionals called “Ages and Stages” that provides resources for feeding, speech, and mouth function. Would you talk to us about this?

DB: As previously mentioned, our mission is to provide the best possible feeding, speech, and mouth development information for families and professionals. We do this through blogs, Q & A’s, and other formats. Our goal is to prevent feeding, speech, and mouth development problems when possible by helping parents keep their children “on track” developmentally through the application of evidence-based information. As a speech-language pathologist, I have worked with many children who have disabilities, but I noticed that parents of typically developing children also needed the information we have (as oral sensory-motor and feeding specialists) to keep their kids “on track.” Our website is www.agesandstages.net where we offer free parent-professional book guides in addition to a lot of other free information.

TS: You also have a number of publications and host trainings. Would you tell us about these projects too and how to access them?

DB: In addition to my two books, I have written a number of journal and popular articles for parents, families, and professionals. These are listed on my website.

I have recently published an E-course on the topic of newborn and infant mouth development entitled Everything You Need to Know about a Baby’s Mouth for Good Feeding, Speech, and Mouth Development. The course is particularly useful for new parents, because it talks about avoiding many of the pitfalls that occur during the first year of life.

While the course was originally developed as a continuing education course for professionals, it’s presented in such a way that parents and care providers can understand and benefit from it. Information on all of my projects can be found on my website.

TS: Finally, as we close our show, would your list your top “Five Fabulous Facts for Families” to provide safe, healthy, and pleasant mouth development experiences?

DB: As I have said in previous interviews, I am providing you with educational information based on my years of experience and study as a clinician. I am not providing medical advice. So, here are five ideas I would like you to take with you:

-Always talk with your pediatrician about the methods and techniques you are using with your child. Your pediatrician is a partner in your child-rearing process, and you learn from one another as you share information about your child.

-If possible, begin tracking and guiding your child’s mouth development from birth. This could save you from expensive orthodontic and other work later on.

-If you have an older child, take a good look at your child’s mouth and airway development. See the appropriate specialists if needed. The sooner you get treatment, the better.

-Heredity plays a part in your child’s structural development, but it is not a reason to skip needed treatment. If underbites, overbites, or other mouth development problems run in your family and your child seems to be headed in that direction, see an orofacial myofunctional therapist, a pediatric dentist, a pediatric otolaryngologist (i.e., ear, nose, and throat doctor), an oral sensory-motor specialist, or other appropriate professional.  

-On my website, I have a websites and companies resource list with a section on mouth structure and function where you can find many resources about mouth and airway development. We are also working on a networking directory to help you find appropriate professionals in your area. In addition, you are always welcome to contact me directly with your questions at agesandstages@cox.net.

You think you understand what the "sensory diet" concept is - really?  Take some time to explore the neuroscience and clinical reasoning that ensures your practice is up to date!

Sensory Diets are commonly utilized by pediatric occupational therapists, including school based therapists, early interventionists, and  general pediatric clinicians.  Most typically, the sensory diet is selected to address a concern related to difficulties in sensory modulation.  The concept of a "sensory diet" (as originated by Patricia Wilbarger) is often included in treatment plans, IEP's, etc.  However, the power of a sensory diet is only as strong as the underlying clinical reasoning.  Unfortunately, many therapists use "sensory tools" without a strong underlying theory base or without grounding the intervention in sound neuroscience principals.  As such, many sensory diets are limited in their impact and this leads families and school teams to not adhere to the prescribed intent, intensity, or scope of the full sensory diet. This can result  in the plan being abandoned or losing its intended focus or purpose.     

This one day course will sharpen your clinical reasoning skills and allow you to harness the power of the sensory diet concept. The course will focus on neurologically based principals that drive the selection and timing of the inputs utilized in the sensory diet.  The course will also bring contemporary issues related to relationship based intervention into the context of the sensory diet concept.   The course helps each clinician to use the sensory diet concept to enhance outcomes and ensure best practice!  


This blog post was contributed by Tracy Murnan Stackhouse, presenter of Session K.

DeDe Wanzek, PT , who will be assisting Mary Massery for her treatment labs at the RAIR Symposium in February, has found the respiratory information and intervention from Massery’s courses very valuable for a variety of development and/or sensory motor problems. She shares a couple of examples from her practice at St. Croix Therapy in Hudson, WI.

A six year old girl was referred for general incoordination with mom reporting that she did not want to play outside and just wanted to do sedentary activities.  After about two months at two treatments per week that included addressing respiration, her mom reported that she was playing on the playground with the boys (she preferred the boys over the girls-thought that was cute).  Her swim teacher noted that her left leg, which had been lagging behind, was moving and coordinated with her other limbs.

Another young lady was referred because she had hit a plateau with her OT treatment and her mom suspected that there were some breathing issues. Indeed there were. She was using an inferior/superior breathing pattern with very tight neck muscles.  In addition she had difficulty with anxiety.  After just two sessions of working with her, she began to incorporate the breathing techniques at home when she began to feel anxious and found benefit.

With toe walkers we have been finding atypical breathing patterns to be an issue.  Generally the rib cage is elevated in relation to their extensor pattern.  I think it would be fascinating to do a study with toe walkers relative to breathing.  We incorporate breathing strategies along with working on the feet and legs and mobilization of the trunk.  We feel that addressing the breathing pattern is very helpful in resolving the toe walking.  

For information regarding Dr. Massery’s upcoming course in the Minneapolis area, click here.

Paul Stadler, MS, OTR/L, NDT wrote this blog on his sessions B. THE IMPACT OF PRIMITIVE REFLEXES ON DEVELOPMENT, SENSORY PROCESSING, AND ACADEMIC ACHIEVEMENT and F. THE INPP DEVELOPMENTAL TEST AND SCHOOL BASED PROGRAM. For more information on these sessions, visit Mr Sadler's blog from last year: A Perspective on Reflex Integration

I am very much looking forward to joining again the Richter Air Symposium on Therapeutic Applications for Pediatrics to present  “The Impact of Primitive Reflexes on Development, Sensory Processing, and Academic Achievement” and “The INPP Developmental Test and School Based Program”. 

Past participants have described these courses as highly informative, lending a fresh perspective on many issues that pediatric therapists face with younger children.  It took until 2008, for a scientist to discover the gene that acts as the trigger mechanism for cell differentiation, the next major step in development after fertilization.  The unraveling of the complexity of childhood development has long been on its way, but we continue to see an emergence of new ideas that tackle delays and difficulties in this.  These courses will engage participants in this direction.  The INPP Developmental Test and School Based Program not only provides the theory and research, but will guide participants through a regimented evaluation and treatment program for groups of children who experience many issues we encounter in the classroom.  As school systems adopt more of a group based provision for services for children across related services, this program further enhances the opportunity for success with children within this complex developmental framework.

Teresa A. May-Benson, ScD, OTR/L, FAOTA

            While identification and treatment of praxis is well understood by most occupational therapists trained in sensory integration, understanding the ideational aspect of praxis typically remains elusive. Identifying ideational difficulties and distinguishing them from motor planning problems can be difficult. May-Benson and Cermak (2007) developed the Test of Ideational Praxis (TIP) to address this problem. Research on the TIP led May-Benson (2006, April) to propose that as many as 50% of children with praxis difficulties demonstrate impaired ideations abilities. Children with ideational difficulties demonstrate a number of characteristics which aide in their identification. They demonstrate difficulties in areas of functioning including motor skills and affordance recognition, language use related to action, behavioral regulation, cognitive/executive function skills and play skills. They routinely have difficulty generating goals for actions and some idea of how to get there. They demonstrate a limited repertoire of motor actions and play themes and have difficulty playing alone. Children with ideation problems tend not to know what to do with new objects or toys, thus they often use all objects in the same way (e.g. bangs) and may use inappropriate actions on objects (e.g. stands on a ball). They may demonstrate the same range of actions as typical peers and children with motor planning problems but demonstrate a decreased frequency, variety and complexity of object interactions which results in a higher frequency of simple actions which do not require much object manipulation (May-Benson, 2006, April). Children with ideational problems have a decreased ability to alter plans or adapt objects from their usual use and are notoriously rigid about changes in routines. These children often develop unworkable plans and may need excessive time to generate ideas for action resulting in a decreased flow of ideas. As a result, these children often require increased reinforcement or encouragement to complete tasks. Memory can also appear to be problematic for these children as they often have difficulty remembering previous games they have played.

            Children with ideational problems, while often scoring within average limits on language assessments, appear to have particular difficulty with the functional use of language related to actions and objects. These children demonstrate difficulty labeling properties of objects, their own body actions, and body/object movements in space. They are often very concrete in their language and do not use or tolerate representational language (e.g. a bolster swing cannot be a car). This lack of representational language contributes to the appearance of a lack of imagination or difficulty pretending. This impacts play skills as they have a restricted repertoire of imaginary play themes that are often re-enactments of specific stories or movies. 

            Ideational deficits are a cognitive difficulty that appears to have its basis in poor sensory-motor exploratory play. However, providing effective intervention for ideational difficulties may be difficult for therapists as these problems do not seem to respond well to traditional sensory integration-based activities alone. Therefore, directed cognitive interventions techniques are needed to effectively treat this area of dysfunction. The author has addressed ideational difficulties for over fifteen years and developed an intervention approach for ideation. The proposed intervention approach involves language-based strategies grounded in cognitive learning theory implemented within the context of a sensory and praxis rich environment. This approach consists of two types of intervention strategies: general strategies to promote ideation and a specific structured combined cognitive-motor approach to address ideational deficits.  To learn more about assessment of and intervention for ideational problems, attend my courses Advanced Assessment for Praxis: Tools for Busy Therapists and Advanced Intervention for Ideation: Affordances to Executive Function.  Also watch my website www.tmbeducation.com for more information on sensory integration, ideation and praxis.


May-Benson, T. A. (2001). A theoretical model of ideation. In E. Blanche, R. Schaaf, & S.Smith Roley (Eds.), Understanding the nature of sensory integration with diverse populations. San Antonio, TX: Therapy Skill Builders.

May-Benson, T.A. (2006, April).  Ideation, language, cognition and behavior in praxis.  Lecture Presented at Children’s Learning Forum, Ohio State University, Columbus, OH.

May-Benson, T. A., & Cermak, S. A. (2007). Development of an assessment for ideational praxis. Am J Occup Ther, 61(2), 148-153. Retrieved from PM:17436836

Contributed by Eileen Richter, MPH, OTR/L, FAOTA

When Ingo Steinbach, the renowned international sound engineer, offered to come to Camp and provide his recently improved auditory therapy for 12 campers, Avanti OTs were intrigued. Many of us had learned listening and sound theory from him when he taught in the US over 10 years ago. That experience for some, was an introduction to the power of auditory physics and it’s connection to brain function and behavior. For others it was an elaboration and refinement of other listening theories they already knew. His information and approach was particularly appreciated by occupational therapists specializing in a sensory integrative approach to treatment.

Very quickly Steinbach’s listening interventions were integrated into sophisticated treatment applications by OTs who continued to study the impact of designed sound intervention by such experts as Tomatis, Berard, Madaul, Frick, Strong and others. The addition of sound and listening strategies has been shown to bring about meaningful changes (DeCleene, K. E., &Hayden-Sewall, A. A) for children with sensory processing disorders and Samonas made a significant contribution to the field.

At Camp Avanti we discovered that with technological advances and additional research, Ingo has been refining his sound therapy strategies, combining diagnostic precision with discreet application of sound/music alterations. He has been able to produce materials that are easier to apply for improved outcomes. We knew we had to bring him back for the RAIR Symposium so that other OTs could access his new programs and materials and understand the auditory neurology and physics that make them effective.

Since his experience at Camp Avanti, Ingo has been designing tools specifically for use by occupational therapists to support child development through the auditory system. They address

- Basic regulation and body functions, 

- Oral motor development, 

- Eye-hand-mouth coordination, 

- Motor and body posture, 

- Engagement, social-emotional development, 

- Cognitive skills.

These tools will be introduced for the first time at Steinbach’s 2-day presentation at the Symposium, February 26-27. The Samonas strategies and technology will be a great addition to occupational therapists working with children with a variety of sensory processing disorders.

DeCleene, K. E., &Hayden-Sewall, A. A. (2007, December). Sound therapy: How did it evolve and what is occupational therapy's role? AOTA; School System Special Interest section Quarterly, 14(4), 1-3.

Judy Michels Jelm, MS, CCC-SLP expanded on why she's excited for session C2.


I am thrilled to be presenting two courses at the Richter AIR Symposium 2015. One course Part II: “My 25 Favorite Oral-Motor Treatment Techniques”, is an interactive course.   Actually, this course could be entitled “”My Favorite……..Techniques and even more” since there will be a time for sharing between participants and myself.  We will discuss, for example, how to manipulate and change oral-motor techniques based a trial exploration and experience.  Since my experiences take into account a wide range of treatment options over multiple decades, I have become a multi-experienced thinker and practitioner. 

I have learned that the power of tool manipulation has become my best friend when learning techniques.   The oral-motor system is a complex system but these complexities will allow you, the participant to open your mind to a vast amount of techniques you might not have considered in the past.  I will share with you and my hope is you will share too.

Part I:  Syncing Oral Motor/Sensory Assessments to Meet Goal Areas will give you a basis for Part II. What assessments do you use?  Does that assessment give you information needed for your treatment session?